Provider Demographics
NPI:1811562887
Name:BRUCE, MACKENZIE ANDRA SHERON (PA)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ANDRA SHERON
Last Name:BRUCE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 SOMERSET PL APT 16
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-3739
Mailing Address - Country:US
Mailing Address - Phone:480-352-8155
Mailing Address - Fax:
Practice Address - Street 1:1704 SOMERSET PL APT 16
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-3739
Practice Address - Country:US
Practice Address - Phone:480-352-8155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-23
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9114831363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program